MHK CareProminenceTM

Integrated medical and pharmacy management

The only platform that combines pharmacy and medical care, MHK CareProminence was purposely built to improve member care by closing care gaps while ensuring continual compliance with changing government regulations.

Additional CMS and Other Regulatory Changes in Light of COVID Outbreak

Additional CMS and Other Regulatory Changes in Light of COVID Outbreak

As we shared in the March 31 Strategic Insights blog, the Centers for Medicare and Medicaid Services (CMS) has delayed or changed many important regulatory activities in 2020 due to the COVID crisis.

We reported at the time that the following were delayed.

CMS Program Audits

Contract-level Risk Adjustment Data Validation (RADV) audits

Since then, additional changes on the regulatory front have been made by CMS and other entities:

CMS stated health plans do not have to submit 2019 HEDIS results for June 2020.

As well, health plans are not required to submit to a CAHPS survey in 2020.

The CMS HOS survey will be postponed until late Summer and could get canceled for the year as well.

The National Committee for Quality Assurance (NCQA) has canceled public comment for NCQA Health Plan Accreditation for 2021. No new elements or changes will occur for 2021.

CMS had already delayed the implementation of the new Integrated Denial Notice (IDN) and this is a reminder that extended deadline has now passed. It was May 15, 2020.

CMS is suspending the 2020 Data Validation of 2019 Part C and D reporting requirements data, with the exception of data for the following reporting sections: Part C Special Needs Plans (SNPs) Care Management and Part D Medication Therapy Management (MTM) Programs. Data submitted for these two reporting sections are the basis for two measures used in the 2021 Star Ratings, which will be used for 2022 payment. Data validation for Part C SNPs Care Management and Part D MTM Programs reporting sections began on Monday, April 20, 2020, and end on Tuesday, June 30, 2020.

CMS is adopting relaxed enforcement of the prohibition on mid-year benefit enhancements if additions are related to the COVID outbreak or are otherwise beneficial to enrollees. Further, these benefits must be available to all similarly situated enrollees.

CMS is allowing health plans to make available smartphones and tablets to facilitate telehealth for enrollees as long as the use is primarily health-related. Plans would need to provide locks and other access controls to ensure this.

CMS has also made Star Rating changes in light of the pandemic. Star ratings are usually announced each October effective for the coming January. Health plans rely on their score to ensure their bids can pass on as many benefits to members via the rate rebate program and quality bonus. Because of the pandemic’s impact on clinical measures in 2020 as well as member surveys, the changes for 2021 and 2022 include:

Certain measures in 2021 will default to the 2020 rating. That is, these will be based on 2019 results rather than 2020. These include:

HEDIS measures

CAHPS measures

In 2021, new plans that were to graduate to rated plans will maintain their new plan Star status and continue to be reimbursed as if they were 3.5 Star rated.

For 2021, CMS could cease collecting data in 2020 on other measures and maintain 2020 ratings as well. This will be determined based on whether the pandemic continues.

For 2022, due to the impacts on quality, the 5% guardrails in the movement of cut points finalized in the 2019 rule will not be implemented. This means that such cut points can move freely due to quality impacts in measures due to COVID.

A hold harmless will be implemented in 2022. Final Star ratings will be calculated with and without improvement measures and the plan will get the higher score in 2022.

If surveys are delayed or impacted, allowances here may also be made in 2022.

Final Call Letter Changes

In April, CMS also published the final Rate and Call Letter for 2021. Remember that most of the policy changes were included in a proposed rule announced at the same time as the draft letter. That has yet to be finalized. This should be out soon.

Here are some highlights in the final letter/rate notice. See our three earlier blogs for additional details.

The effective growth rate was revised from about 3% to just over 4%. This pushes the expected average change in revenue to 1.66% from just below 1%. However, there are still expected coding trends that should result in a further increase of 3.56%.

Per the interim rule, 2021 rates will be calculated using 75% of the risk score for 2020 MA model using encounter data and 25% for the 2017 MA model using traditional risk adjustment (RAPS) data.

Effective January 1, 2021, MA plans will no longer be responsible for organ acquisition costs for kidney transplants and these costs will be excluded from the rate benchmarks.

Marc S. Ryan serves as MHK’s President and was one of MHK’s first executives shortly after its founding in 2010. Most recently, Marc served as MHK’s Executive Vice President and Chief Operating Officer and before that as its Chief Strategy and Compliance Officer.

Prior to joining MHK, Marc held a number of executive-level regulatory, compliance, business development, and operations roles at a number of health plans. He launched and operated plans with Medicare, Medicaid, commercial and Exchange lines of business.

He also was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program.

Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He was also nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was also inducted into Sigma Beta Delta, a national honor society for business, management and administration.

MHK, part of the Hearst Health network, is a Medical House of Knowledge, where care and knowledge converge. The only service provider that combines pharmacy and medical, MHK’s mission is to drive better member care in a changing healthcare environment by bringing every care moment in a person’s health journey together through an integrated platform. MHK is committed to helping health plans, PBMs, and provider organizations improve quality of care, enhance operational efficiency, maximize revenue, and meet compliance demands. Three of the top five and six of the top ten health plans are served by MHK and forty percent of all 4-5 Star Medicare health plans utilize MHK solutions.